Child Care Assessment Survey

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* 1. Name of Employer

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* 2. Which of the following best describes your interest in this survey?

Parent, guardian or primary caregiver

Other family member to children who require child care

Future parent

Other (please specify)

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* 3. How many children do you have in the following age groups that need child care?

0-2 years of age

3-4 years of age

5-12 years of age

Before/After School Care (K-6th grade)

After School Care (7th-9th grade)

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* 4. Do you have a child with special needs that requires child care?

Yes

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* 5. Has the lack of child care services prevented you from being able to show up for work or reduced the number of hours you could work?

Yes

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* 6. What challenges do you currently experience with your primary child care arrangements? Please select all that apply.

Availability of care

Location

Hours

Cost

Quality of care

Care during various times of year ( i.e. school breaks and summer)

I do not have any challenges.

Other (please specify)

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* 7. What type of care are you currently using? Please check all that apply.

Care by parent/guardian

Care by relative/friend

Child Care center

Licensed in-home Child Care

Unlicensed in-home Child Care

School-based program

Currently searching for care

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* 8. I currently spend the following each month on child care per child.

0-$150

$151-$300

$301- $500

$501-$750

$751 - $1500

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* 9. In your most recent search for child care, how many providers did you contact before securing care?

1-2

3-5

Cannot recall

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* 10. The fees my family currently pay for child care are afforable

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

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* 11. Are you currently receiving a child care subsidy?

Yes, TANF (Temporary Assistance for Needy Families)

Yes, WIC (Women, Infants & Children)

Yes, an additional supplement for child(ren) with special needs

Yes, I receive assistance from my employer

No, I do not need it

No, I do not qualify

Other (please specify)

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* 12. Please indicate the child care schedule you need for each child

	Mon-Fri Full day	Saturday/Sunday	Variable Days	Casual/Drop-in Coverage	Overnight	Early morning	Early evening	School breaks including summer
Child 1	Child 1 Mon-Fri Full day	Child 1 Saturday/Sunday	Child 1 Variable Days	Child 1 Casual/Drop-in Coverage	Child 1 Overnight	Child 1 Early morning	Child 1 Early evening	Child 1 School breaks including summer
Child 2	Child 2 Mon-Fri Full day	Child 2 Saturday/Sunday	Child 2 Variable Days	Child 2 Casual/Drop-in Coverage	Child 2 Overnight	Child 2 Early morning	Child 2 Early evening	Child 2 School breaks including summer
Child 3	Child 3 Mon-Fri Full day	Child 3 Saturday/Sunday	Child 3 Variable Days	Child 3 Casual/Drop-in Coverage	Child 3 Overnight	Child 3 Early morning	Child 3 Early evening	Child 3 School breaks including summer
Child 4	Child 4 Mon-Fri Full day	Child 4 Saturday/Sunday	Child 4 Variable Days	Child 4 Casual/Drop-in Coverage	Child 4 Overnight	Child 4 Early morning	Child 4 Early evening	Child 4 School breaks including summer
Child 5	Child 5 Mon-Fri Full day	Child 5 Saturday/Sunday	Child 5 Variable Days	Child 5 Casual/Drop-in Coverage	Child 5 Overnight	Child 5 Early morning	Child 5 Early evening	Child 5 School breaks including summer
Child 6	Child 6 Mon-Fri Full day	Child 6 Saturday/Sunday	Child 6 Variable Days	Child 6 Casual/Drop-in Coverage	Child 6 Overnight	Child 6 Early morning	Child 6 Early evening	Child 6 School breaks including summer

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* 13. How could the quality of care be improved for your child(ren)? Check all that apply.

More educational/learning opportunities

Better ratio of indoor to outdoor play (weather permitting)

Better ratio of staff to children

Better communication between provider and family

More nutritious meals/snacks

Provider (staff) that has better training and background in child care

A safer and well-maintained environment

More age-appropriate opportunities

Other (please specify)

Child Care Assessment Survey

Question Title

* 1. Name of Employer

Question Title

* 2. Which of the following best describes your interest in this survey?

Question Title

* 3. How many children do you have in the following age groups that need child care?

Question Title

* 4. Do you have a child with special needs that requires child care?

Question Title

* 5. Has the lack of child care services prevented you from being able to show up for work or reduced the number of hours you could work?

Question Title

* 6. What challenges do you currently experience with your primary child care arrangements? Please select all that apply.

Question Title

* 7. What type of care are you currently using? Please check all that apply.

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* 8. I currently spend the following each month on child care per child.

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* 9. In your most recent search for child care, how many providers did you contact before securing care?

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* 10. The fees my family currently pay for child care are afforable

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* 11. Are you currently receiving a child care subsidy?

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* 12. Please indicate the child care schedule you need for each child

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* 13. How could the quality of care be improved for your child(ren)? Check all that apply.

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* 14. What is most important to you relating to your child care needs at the present time (ranking from 1-7, 1 being most important)?